急性双侧脑梗死临床特点及病因分型和预后

Clinical Characteristics,Etiological Classification and Prognosis of Acute Bilateral Cerebral Infarction

目的比较急性双侧脑梗死不同于单侧脑梗死的临床特点、病因分型及预后。方法将2年间确诊为急性脑梗死的患者分为单侧脑梗死组与双侧脑梗死组,回顾分析临床资料。结果749例急性脑梗死中双侧组70例(9.3%),单侧组679例(90.7%)。既往卒中史比例(30.0%vs 18.9%)和D-二聚体水平[(1.93±4.87)mg/L vs(0.67±1.70)mg/L]双侧组较单侧组高(P<0.05),性别、年龄、并发出血、高血压、糖尿病、心房颤动史、吸烟史、最严重时NIHSS评分、LDL-C、FBG、PLT、FIB、HCY等组间差异无统计学意义(P>0.05)。双侧组病因分型依次为大动脉粥样硬化型(LAA)29例(41.4%),不明原因型(SUE)22例(31.4%),心源性栓塞型(CE)12例(17.1%),其他原因型(SOE)4例(5.7%),小动脉闭塞型(SAO)3例(4.3%),单侧组病因分型依次为LAA 324例(47.7%),SAO 259例(38.1%),CE 62例(9.1%),SUE 24例(3.5%),SOE 10例(1.5%),双侧组CE、SOE、SUE占比高于单侧组(P<0.05),单侧组SAO占比高于双侧组(P<0.001),LAA占比组间差异无统计学意义(P>0.05)。双侧组按累及病灶分为后循环组23例(32.9%)、前循环组26例(37.1%)、前后循环组21例(30.0%),后循环组LAA型占78.3%,高于前循环组(38.5%)和前后循环组(4.8%)(χ^(2)=7.8、24.2,P<0.01);前后循环组SUE型占比为66.7%,高于后循环组(8.7%)和前循环组(23.1%)(χ^(2)=9.0、15.9,P<0.01)。双侧脑梗死发病机制依次为机制不明(31.4%),动脉-动脉栓塞(30.0%),心源性栓塞(17.1%),血栓形成(12.9%),低灌注/栓子清除障碍(4.3%),其他(4.3%)。双侧组与单侧组最严重时mRS评分0~2分和≥3分的占比差异均无统计学意义(P>0.05),发病3个月mRS评分≥3分双侧组占比高于单侧组(24.3%vs 15.0%,χ^(2)=4.075,P=0.044)。结论急性脑梗死中双侧脑梗死约占9.3%,既往卒中史和D-二聚体水平高易致双侧脑梗死,我国现有诊断条件下LAA、SUE、CE是主要病因,双侧后循环以LAA型多见,前后循环均有病灶的患者病因较难确定,双侧脑梗死预后不良率高于单侧脑梗死。

Objective To compare the clinical characteristics,etiology classification and prognosis of acute bilateral cerebral infarction different from unilateral cerebral infarction.Methods Patients diagnosed with acute cerebral infarction in the past 2 years were divided into unilateral cerebral infarction group and bilateral cerebral infarction group,and the clinical data were retrospectively analyzed.Results Among the 749 cases of acute cerebral infarction,70 cases(9.3%)were in the bilateral group and 679 cases(90.7%)were in the unilateral group.Proportion of previous stroke history(30.0%vs 18.9%)and D-dimer level[(1.93±4.87)mg/L vs(0.67±1.70)mg/L]in the bilateral group was higher than the unilateral group(P<0.05),gender,age,hypertension,diabetes,fibrillation,smoking history,NIHSS score,LDL-C,FBG,PLT,FIB,HCY,etc.had no statistical significance(P>0.05).The etiology classification of the bilateral group was as follows:LAA 29 cases(41.4%),SUE 22 cases(31.4%),CE 12 cases(17.1%),SOE 4 cases(5.7%),SAO 3 cases(4.3%),the etiology classification of the unilateral group was LAA 324 cases(47.7%),SAO 259 cases(38.1%),CE 62 cases(9.1%),SUE 24 cases(3.5%),SOE 10 cases(1.5%).The proportion of CE,SOE and SUE in the bilateral group was higher than that in the unilateral group(P<0.05),the proportion of SAO in the unilateral group was higher than that in the bilateral group(P<0.001),LAA in groups was not statistically significant(P>0.05).The bilateral cerebral infarction was subdivided into the posterior circulation group with 23 cases(32.9%),the anterior circulation group with 26 cases(37.1%),the anterior and posterior circulation group with 21 cases(30.0%),the accounted for LAA type 78.3%in the posterior circulation group,which was higher than the anterior circulation group(38.5%)and the anterior and posterior circulation group(4.8%)(χ^(2)=7.8,24.2,P<0.01),the anterior and posterior circulation group SUE type 66.7%which was higher than that of the posterior circulation group(8.7%)and the anterior circulation group(23.1%)(χ^(2)=9.0,15.9,P<0.01).The pathogenesis of bilateral cerebral infarction is in the order of unknown mechanism(31.4%),arterial-arterial embolism(30.0%),cardiogenic embolism(17.1%),thrombosis(12.9%),hypoperfusion/embolization disorder(4.3%),others(4.3%).There was no significant difference in the proportion of the unilateral group and the bilateral group in the most severe mRS scores(P>0.05).The proportion of the mRS scores of the bilateral group≥3 points at 3 months after the onset was 24.3%,which was higher than that of the unilateral group(15.0%,χ^(2)=4.075,P=0.044).Conclusion Bilateral cerebral infarction accounts for about 9.3%of acute cerebral infarction.Past stroke history and high D-dimer levels are likely to cause bilateral cerebral infarction.Under the current diagnosis conditions in my country,LAA,SUE,and CE are the main causes.LAA is more common in bilateral posterior circulation group.It is difficult to determine the cause of patients with lesions in the anterior and posterior circulation.The poor prognosis rate of bilateral cerebral infarction is higher than that of unilateral cerebral infarction.